PPO II - EmblemHealth

More documents

Recommendations

Info

2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Section 10.3 Step-by-step: Making a complaint Step 1: Contact us promptly – either by phone or in writing. • Usually, calling Customer Service is the fi rst step. If there is anything else you need to do, Customer Service will let you know. Our phone number and hours of operation are 1-866-557-7300, Monday-Sunday 8:00 am to 8:00 pm (TTY: 1-866-248-0640). If you do not wish to call (or you called and were not satisfi ed), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. A member grievance must be fi led within 60 days of the date of the incident causing the complaint by writing to: EmblemHealth Medicare PPO ATTN: Grievance and Appeals PO Box 2807 New York, NY 10116-2807 or in person at: EmblemHealth Medicare PPO 55 Water Street New York, NY 10041 Th e hours of operation are Monday-Friday, 8:30 am - 5:00 pm. No appointment is necessary. If you have someone fi ling a complaint for you, your complaint must include an “Appointment of Representative Form” authorizing the person to represent you. To get the form, call Customer Service (phone numbers are on the back of this booklet) and ask for the “Appointment of Representative Form.” It is also available on Medicare’s website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf or on our website at www.emblemhealth.com/medicare. While we can accept a complaint without the form, we cannot complete our review until we receive it. If we do not receive the form within 44 days after receiving your complaint request (our deadline for responding to your complaint), your complaint request will be closed. A written acknowledgement will be sent to you within 15 days after the date the grievance was received by EmblemHealth Medicare. It will include a request for any additional information needed to resolve the grievance and will identify the name, address and phone number of the department which has been designated to respond to it. We will investigate your grievance, and notify you of our decision as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your grievance. We may extend the time frame by up to 14 calendar days if you request an extension, or if we justify a need for additional information and the delay is in your best interest. We will notify you if an extension is needed. If you request an expedited organization determination, expedited coverage determination, expedited reconsideration or expedited redetermination, we may decide your request does not meet the criteria to expedite, and therefore will process your request using the timeframes for a standard request. If we decide not to expedite your request, or decide to take an extension on your request, you may request an expedited grievance. EmblemHealth must respond to your expedited grievance within 24 hours of the request. 191
192 2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) • Whether you call or write, you should contact Customer Service right away. Th e complaint must be made within 60 calendar days after you had the problem you want to complain about. • If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours. Legal Terms What this section calls a “fast complaint” is also called an “expedited grievance.” Step 2: We look into your complaint and give you our answer. • If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that. • Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. • If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not. Section 10.4 You can also make complaints about quality of care to the Quality Improvement Organization You can make your complaint about the quality of care you received to us by using the step-by-step process outlined above. When your complaint is about quality of care, you also have two extra options: • You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to us). � Th e Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients. � To fi nd the name, address, and phone number of the Quality Improvement Organization for your state, look in Chapter 2, Section 4, of this booklet. If you make a complaint to this organization, we will work with them to resolve your complaint. • Or you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to us and also to the Quality Improvement Organization.
Page 1 and 2:
H5528_123133 EVIDENCE OF COVERAGE Y
Page 3 and 4:
ii 2013 Evidence of Coverage for PP
Page 5 and 6:
iv 2013 Evidence of Coverage for PP
Page 7 and 8:
2 2013 Evidence Evidence of Coverag
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
10 2013 Evidence Evidence of Covera
Page 17 and 18:
12 Th ese rules apply for employer
Page 19 and 20:
14 2013 Evidence of Coverage for PP
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
26 SECTION 5 SOCIAL SECURITY 2013 E
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
48 2011 Evidence of Coverage for 20
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
82 2011 Evidence of Coverage for HM
Page 89 and 90:
84 2011 Evidence of Coverage 2013 f
Page 91 and 92:
86 2013 Evidence of Cover age for P
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Page 105 and 106:
100 2013 Evidence of Cover age for
Page 107 and 108:
102 2013 Evidence of Coverage for P
Page 109 and 110:
104 • Chapter 5 of this booklet.
Page 111 and 112:
Page 113 and 114:
108 Your share of the cost when you
Page 115 and 116:
Page 117 and 118:
112 These payments are not included
Page 119 and 120:
114 � Some vaccines are considere
Page 121 and 122:
Page 123 and 124:
Page 125 and 126:
Page 127 and 128:
122 2011 Evidence of Coverage for H
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146: 140 2011 Evidence of Coverage for H
Page 147 and 148: 142 2013 Evidence of Coverage for P
Page 195: 190 2013 Evidence of Coverage for P
Page 221: 55 Water Street, New York, New York
show all

PPO II - EmblemHealth

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?